Introduction of Clinical Pathology PracticalHematology & UrinalysisBy: Dr.dr.Tinny Rasjad Indra SpPK(K)

HematologyBlood samplingHemoglobin assessmentErythrocyte sedimentation rateHematocriteBlood countingBlood smear (Differential count, Blood smear evaluation)Coagulation testBlood groupingCross matchCoombs test

UrinalysisMacroscopicChemicalMicroscopic

PRACTICAL HEMATOLOGY

Lokasi Penyadapan DarahKapiler vol. darah kurang 0,5 ml- 3 jari tengah tangan- tumit, ibu jari kakiVena vol. darah lebih 0,5 ml- vena superfisialArteri analisa gas darah- a. Radialis- a. Femoralis

*

Alat & BahanSimpul hidupDesinfeksi denganalkohol 70%

Vena MedianaCubitiTusukan jarumCara menuangkan darah

*Kegagalan venapungsi

Summary of six blood preparation

HEMOGLOBIN [SAHLI]THE OBJECTIVE HEMOGLOBIN (HB) CONCENTRATION ASSESSMENT

THE PRINCIPLE HB + HCL 0,1 N HEMATINIC ACID, AND THAN COMPARE WITH STANDARD COLOR

3. THE EQUIPMENTS Hb Meter Sahli Consist of Standard colorHemometer tube scale 2 22 g/dLThe glass stickSahli Pipette vol. 20 ulHCl 0,1 N + Pasteur Pipette

4. EXAMINATION PROCEDUREFill the hemometer tube with HCl 0,1 N level 2Fill Sahli pipette with 20 l blood and keep the outer site clean from bloodMove this blood to hemometer tube and clean pipette with HCl.Wait for 5 minutes, for yielding hematinic acid.Dilute with destilated water until its color equal with colored glass standardRead the result as Hemoglobin levels (g/dL)

7. NORMAL VALUE : MAN : 14 18 g/dl WOMAN : 12 16 g/dl8. SOURCE OF TROUBLE SHOOTS IMPROPER INSTRUMENTS / REAGENTS a. SAHLI PIPETTE VOLUME NOT PRECISE 20 l b. STANDARD COLOR PALE c. HCL CONCENTRATION NOT PRECISE 0.1 N OPERATOR MISCONDUCT a. INACCURATE BLOOD FILL ( 20 l)b. VISUAL PROBLEM c. DIDNT CLEAN THE BLOOD PIPETTE d. DIDNT RINSE THE PIPETTE WITH HCL e. IMPROPER DILUTION

ERYTHROCYTE SEDIMENTATION RATE(WESTERGREN)THE PRINCIPLEBLOOD + ANTICOAGULANT WHEN PLACED IN A CERTAIN VALUE TUBE THE ERYTHROCYTES SLOWLY SINK TO THE BOTTOM OF THE TUBE TEST. THE GOALTO MEASURE THE ERYTHROCYTE SEDIMENTATION RATE

3. EQUIPMENTS WESTERGREN TUBE 1. LENGTH 300 mm 2. DIAMETER 2,5 mm 3. SCALE 0 200 mm 4. OPENED BOTH TIPSb)WESTERGREN RACKSUCKERTIMERBOTLE SALINE (NaCl 0,9%)

5. PROCEDURESUCK SALINE UNTIL LEVEL 150, THEN PUT IT INTO AN EMPTY BOTTLE.SUCK BLOOD-EDTA WITH WESTERGREN TUBE UNTIL 0 LEVEL THEN PUT IT INTO THOSE SAME BOTTLESHAKE THE MIXTURE THOROUGHLYSUCK THE MIXTURE INTO WESTERGREN TUBE UNTIL 0 LEVELPUT THE TUBE ON THE RACK VERTICALLYWAIT FOR 1 HOUR (USE TIMER)READ THE RESULT (mm/hour)

READ THE RESULT11 mm5 mm

HEMATOCRIT ASSESSMENT (PCV)WINTROBE METHODEQUIPMENTS WINTROBE TUBESYRINGE FOR FILL BLOOD INTO A TUBECENTRIFUGE

PROCEDURE

FILL BLOOD-EDTA INTO WINTROBE TUBE USING SYRINGE UNTIL REACH LEVEL 10 IN THE UPPER PARTCENTRIFUGES 3000 RPM FOR 30 MINUTESREAD THE RESULT (IN %)

EQUIPMENT FOR WHITE BLOOD COUNT

Improved Neubauer Counting Chamber

Blood SmearPERIPHERAL BLOOD SMEAR EVALUATION: EVALUATE ERYTHROCYTE, LEUCOCYTE & THROMBOCYTELEUCOCYTE DIFFERENTIAL COUNT:COUNT A NUMBER OF EACH LEUCOCYTE TYPE

BLOOD SMEAR PREPARATIONPLACE A DROP OF BLOOD ON OBJECT GLASS ABOUT 2 cm FROM THE MARGIN. PUT ON THIS OBJECT GLASS ON THE DESK IN THE RIGHT SIDE OF EXAMINER.PLACE A COVER GLASS (SPREADER SLIDE) IN THE LEFT SIDE OF THE BLOOD DROP MOVE IT SLOWLY WITH ANGEL ABOUT 45O TO THE RIGHT UNTIL REACH THE BLOOD DROP

LET THE BLOOD SPREAD QUITE ON THE EDGE OF THE SPREADER SLIDE

PUSH SPREADER SLIDE AHEAD OF THE DROP OF BLOOD IMMEDIATELY WITH 30 45.

LET IT DRY IN AIR , AND THEN STAIN WITH WRIGHT OR GIEMSA STAIN

WRIGHT STAININGPLACE 12 DROPS WRIGHT STAIN IN BLOOD SMEAR 2 MINUTESADD BUFFER SOLUTION IN EQUAL VOLUME BLOW IT UNTIL METALIC SCUM APPEARWAIT FOR 20 MINUTESRINSE WITH FLOW WATERDRY IT IN AIR

BLOOD SMEAR PREPARATION IS GOOD IF :HAVE A COUNTING AREA.LEUCOCYTE TYPE ARE DISTINGUISHABLETHERE IS NO PRECIPATED STAIN

Blood Smear ExaminationFocus the microscope on the slide using the x10 (low power) objective.Is the blood smear preparation good?Estimate the white cells count (normal/decrease/increase)When 20 30 leukocyte / area -> 5.000 / mm3 40 50 leukocyte / area -> 10.000 / mm3

2. Add a drop of immersion oil, and switch to the high power (x100) (oil immersion) objective.- Erytrocyte : - size, shape, color. - Imature cells (normoblas) - Abnormal cells- Trombosit : - Count estimation :8-10 / area -> Normal - MorphologyNormal/AbnormalLeukocyte : - Differential count - Morphology (Normal/Abnormal)

AYAMA. ERITHROCYTEB. LARGE LIMPHOCYTEC. SEGMENTED NEUTROPHYLD. EOSINOPHYLABCD

BEBEKA. ERITHROCYTEB. LARGE LIMPHOCYTEAB

PUYUHA. ERITHROCYTEB. LARGE LIMPHOCYTEAB

MENCITA. ERITHROCYTEB. LARGE LIMPHOCYTEC. Segmented NeutrofilD. Trombosit / PlateletABCD

DOMBAA. ERITHROCYTEB. LARGE LIMPHOCYTEC. Segmented NeutrofilD. Trombosit / PlateletE. EosinofilABCDE

SAPIA. ERITHROCYTEB. LARGE LIMPHOCYTEC. Segmented NeutrofilD. Trombosit / PlateletE. EosinofilABCDE

HASIL AUTOANALIZER

HASIL AUTOANALIZER

HASIL AUTOANALIZER

HASIL AUTOANALIZER

LEUCOCYTE DIFFERENTIAL COUNTThe presentage distribution of different type of leucocyteImportance in the diagnosis and prognosis of disease processesEo / Ba / Stab / Segment / Lym / Mo

DIFF COUNT CALCULATION MAKE 10 ROWS FOR EACHLEUCOCYTE TYPE

12345678910%EoBaStSgLyMo

12345678910%EoI-Ba-IStII-SgIIII IIIIILyIIIIIMo-I

NORMAL VALUE OF DIFF. COUNT EOSINOPHYL : 1 3 % BASOPHYL : 0 1 % BAND : 2 6 % SEGMENT : 50 70 % LYMPHOCYTE : 20 40 % MONOCYTE : 2 8 %

AUTO ANALYZER HEMATOLOGY20 PARAMETERS / 3 MINUTES

BLEEDING TIME BLOOD COAGULATION

ReagentsBLOOD GROUPING

Anti AAnti BAnti ABGroup OAnti AAnti BAnti ABGroup AB

MAJOR CROSS MATCH NEGATIVE RESULTMINOR CROSS MATCH POSITIVE RESULTCROSS MATCH REACTION

URINALYSISMacroscopic:Color, clear, pHChemical:Protein, glucose, ketone, bilirubin, and urobilirubinMicroscopic:Sediment

Reduction Test (Benedict)Negative control+ 1+ 2+ 3+ 4

Proteinuria Test(Heat)Negativecontrol + 1+ 2+ 3+ 4

Ketone Test(Rothera)Strong positiveNegative control

Bilirubin TestNegativecontrolPositive

Kepaniteraan Umum UrinalisisLaboratorium Patologi Klinik FK Unibraw/RSU dr. Saiful Anwar Malang

Urinalisis

Makroskopik: warna, kejernihan; fisik: volume dan berat jenisKimiawi : protein, glukosa, keton, bilirubin, urobilin (manual atau dipstik/tablet testing) Mikroskopik : sedimen

Pemrosesan sampelSentrifus 1500-2000 rpm, 5 menitUntuk kimiawi konvensionalUntuk mikroskopis (1 cc)10-12 ml Urin

Pemrosesan sampelKemudian sentrifus 1500-2000 rpm, 5Untuk mikroskopis (1 cc)10-12 ml urin, kocok: Untuk kimiawi dipstikdibuang

Pemeriksaan Kimia StikPemeriksaan urin dengan menggunakan reagen kimia kering berupa stik atau pita dengan parameter pengukuran meliputi berat jenis, lekosit esterase, nitrit, pH, protein, glukosa, keton, urobilin, bilirubin, dan darah/Hb.

ProsedurGunakan urin segar, tidak disentrifus, homogenkan sebelum pemeriksaanCelupkan stik ke dalam urin Ketika menarik stik geserkan sisi stik di tepi wadah untuk membuang kelebihan urinMiringkan sebentar di atas kertas tissue untuk mengurangi kelebihan urin Tunggu selama 30 60 detik, tidak boleh lebih dari 2 menit.Baca hasil, bandingkan dengan warna indikator

Specific gravity (Berat jenis)Berkaitan dengan osmolalitas urin Memberikan petunjuk penting status hidrasi penderita. Menggambarkan kemampuan konsentrasi ginjal. BJ normal: 1,003 sampai 1,030

Makroskopik atau mikroskopik hematuriaPemeriksaan dipstik darah dalam urin mendeteksi aktifitas peroksidase eritrosit. Mioglobin dan hemoglobin juga dapat mengkatalisa reaksi ini.Hematuria dibagi menjadi menjadi 3 berdasarkan etiologinya, glomeruler, renal (nonglomeruler), dan urologik Hematuria

ProteinuriaPemeriksaan yg paling dapat menunjukkan adanya kelainan ginjal.Terutama protein serum BM rendah yg dapat difiltrasi oleh glomerulus & yg dihasilkan di dalam genitourinary tract. Diantaranya, albumin. Proteinuria: ekskresi protein urin lebih dari 150 mg/hari (10 - 20 mg/dL); petanda khas penyakit ginjal. Mikroalbuminuria: ekskresi 30 - 150 mg protein/hari

Glukosuria terjadi jika beban glukosa yang difiltrasi melebihi kemampuan tubulus mereabsorbsinya.Keton = produk intermediate metabolisme lemak, yaitu, aseton, acetoacetic acid, & beta-hydroxybutyric acid. Ketonuria: saat penggunaan karbohidrat sangat berkurang dan simpanan lemak harus dimetabolisme untuk suplai energi.Ketonuria sebagian besar berkaitan dengan diabetes yang tak terkontrol Glukosuria & Ketonuria

Normal tidak ditemukan di dalam urin. Positif jika bakteri mereduksi nitrat urin menjadi nitrit. Positif: organisme ini terdapat dalam jumlah yang bermakna (> 10.000/mL).Hasil positif membantu, tetapi hasil negatif tidak menyingkirkan ISK. Nitrit

Leukosit esterase diproduksi oleh neutrofil dan dapat menunjukkan piuria yang berkaitan dengan ISK. Uji kimiawi untuk leukosit tidak dirancang untuk mengukur jumlah leukosit, dan direkomendasikan penghitungan leukosit dilakukan dengan pemeriksaan mikroskopik. Leukosit esterase

Bilirubin dan UrobilinogenBilirubinuria: perlu evaluasi lebih lanjut kelainan fungsi hepar dan obstruksi bilier.Urin normal mengandung hanya sedikit urobilinogen, produk akhir conjugated bilirubin setelah melewati bile ducts & dimetabolisme di dalam usus. Urobilinogenuria: Hemolisis dan penyakit hepatoseluler

10 12 ml ke dalam tabung sentrifus2000 rpm/5 menit Tuang cairan bag atas, kembali cepat tapi lembut, segera tegakkan, sisa 0,5-1 mlUrinalisis Mikroskopik (Sedimen)

Kocok untuk resuspensi sedimen, teteskan 1 tetes Tutup dengan gelas penutup Amati dibawah mikroskop oby 10 x (LPK) & 40x (LPB)

SedimenEritrosit : N: 0 2 /lpb (400X)

Dismorfik

Sedimen Leukosit Normal: 0 5 /LPB Epitel

Silinder hialin

Silinder granuler kasarSilinder granuler halus

Silinder epitel

Silinder leukosit

Silinder Eritrosit

Oval Fat BodiesTrikomonasWaxy castRough granular cast

ErythrocyteSEDIMENT

AGGREGATE LEUCOCYTEAIM SEDIURI-STAIN

HYALIN CYLINDERAIM SEDIURI-STAIN

SILINDER LEKOSIT

Coarsly Granular Cylinder

Contaminated UrineBacteriYeastLeucocyte

*****************************